Print an application

Applying for enrollment in UPMC for Life is easy

Follow the steps below to apply for enrollment in a UPMC for Life plan.

  1. Choose the UPMC for Life plan in which you would like to apply for enrollment.
    Click here
    to compare plan options and benefits.

  2. Apply for enrollment. We offer three different ways to apply:
    • Call us toll-free at 1-866-400-5077 to apply for enrollment over the phone. Representatives are available seven days a week from 8 a.m. to 8 p.m.* TTY users should call 711.
    • Apply online using our secure enrollment website.
    • Print and mail your enrollment application. Click on the enrollment application for your area to download and print.



      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form
      Enrollment Application Form

      After you have completed the enrollment application form, mail it to us at:
      UPMC for Life
      PO Box 2967
      Pittsburgh, PA 15230-9474

  3. We will contact you once your enrollment application has been processed.

You can also enroll online via the Medicare website at Medicare.gov.

This information is not a complete description of benefits. Call 1-866-405-8762 (TTY: 711) for more information. Out-of-network/non-contracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). We are available October 1 through March 31, seven days a week from 8 a.m. to 8 p.m. From April 1 through September 30, we are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m.

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plan has a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., and UPMC for You Inc.

Tivity Health, SilverSneakers, SilverSneakers FLEX and SilverSneakers BOOM are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. © 2018. All rights reserved

*Our hours of operation change twice a year.

You can call us:

October 1 through March 31:
seven days a week from 8 a.m. to 8 p.m.

April 1 through September 30:
Monday through Friday: 8 a.m. to 8 p.m.
Saturday: 8 a.m. to 3 p.m.

Y0069_191055

Last Updated: 10/01/2018
Apple Store Google Play